Consent to Participate in a Telemedicine Appointment
I understand that my healthcare provider wishes me to engage in a telemedicine consultation using Doxy.me.
My healthcare provider has explained in the Telemedicine Letter to Patients how the Doxy.me video conferencing technology will be used to affect such a consultation and will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.
I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my healthcare provider or I can discontinue the telemedicine consult/visit if it is felt that the Doxy.me videoconferencing connections are not adequate for the situation.
I understand that if others are present during the consultation other than my healthcare provider, they will maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following:
- omit specific details of my medical history/physical examination that are personally sensitive to me and/or
- ask non-medical personnel to leave the telemedicine examination room and/or
- terminate the consultation at any time.
I have had the alternative to a telemedicine consultation explained to me as being an in-office visit, and I am choosing to participate in a Doxy.me telemedicine consultation.
I will have a direct conversation with my healthcare provider, during which I will have the opportunity to ask questions in regard to this procedure. I will not proceed with the visit until:
- all my questions have been answered
- I understand the risks, benefits, and any practical alternatives
- the above has been done in a language in which I understand.
By participating in a telemedicine visit with my healthcare provider, I certify:
- That I have read or had this form read and/or had this form explained to me.
- That I fully understand its contents including the risks and benefits of the procedure(s).
- That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.
Telemedicine Consent (PDF)